Reassessing hemodialysis adequacy in children: the case for more

Several lines of evidence support an upward revision in pediatric hemodialy sis dose guidelines: Although current recommendations are derived largely f rom studies of dialysis mortality and morbidity in adults, recent reports o f improved growth and pubertal development with more intensive dialysis hig hlight the need for appropriate pediatric outcome measures in the assessmen t of dialysis adequacy, particularly in prepubertal patients. Even if adult studies can be extrapolated directly to younger patients, reappraisal of t hese data would appear to justify an increase in recommended dialysis clear ances, based on higher dietary protein intake and accumulating evidence tha t adults, too, benefit from more intensive therapy. Suboptimal dialysis may also occur when dialysis dose is overestimated by urea kinetic models that fail to account for compartment effects and post-treatment urea rebound. S tudies comparing the available models in pediatric patients have appeared r ecently, and a few models have been developed specifically for pediatric ap plications. These should permit more reliable estimates of solute clearance for a much-needed multicenter trial to clarify optimal dialysis thera py f or growing children.